EPIC Head Injury Guidelines Michigan: Revolutionizing TBI Care

Last Updated on August 16, 2025 by Beth Skwarecki

Traumatic brain injury (TBI) affects nearly 1.7 million Americans each year, making it one of the most significant public health challenges facing emergency medical services. The consequences extend far beyond the initial trauma, often determining whether a patient will survive, recover fully, or face lifelong disability. For decades, emergency medical professionals have struggled with inconsistent treatment protocols and outdated practices that inadvertently worsened patient outcomes.

The Excellence in Prehospital Injury Care (EPIC) guidelines mark a groundbreaking change in TBI management. Developed through extensive research and successfully implemented in Arizona. 

Evidence-based protocols have shown remarkable outcomes:

• Doubling survival rates across all age groups. 
• Achieving up to 700% higher survival odds in pediatric patients. 

The success of EPIC in Arizona has gained national attention, including among Michigan emergency medical professionals aiming to improve TBI treatment outcomes. 

Implementing EPIC guidelines goes beyond following protocols:

• It requires a fundamental shift in how prehospital TBI care is approached. 
• Simple, correctly applied interventions during the critical first minutes after injury can mean the difference between life and death. 

Michigan’s emergency medical services have the opportunity to:

• Transform their approach to head injury management. 
• Adopt proven strategies to improve patient outcomes. 
  

What Are the EPIC Guidelines?

Comprehensive Approach to Traumatic Brain Injury (TBI): 

EPIC guidelines focus on preventing secondary brain injury during the critical prehospital phase. Developed through extensive research and validated in the largest-scale evaluation of prehospital TBI treatment guidelines globally, EPIC provides a systematic framework for emergency medical services personnel.

Key Principles of EPIC Guidelines: 

EPIC centers around three fundamental principles to prevent secondary brain injury: 

1. Preventing and rapidly correcting hypoxia (low blood oxygen levels). 
2. Avoiding hyperventilation in patients needing assisted ventilation. 
3. Preventing or treating hypotension (low blood pressure). 

Role of Prehospital Care in Patient Outcomes:

Prehospital care plays a critical role in preventing secondary injury, which develops over time and can be mitigated with proper interventions. 

Unlike primary injuries caused by the initial trauma, secondary brain injuries are preventable through high-quality, evidence-based emergency care. 

This shifts the focus from just transporting patients quickly to delivering effective care during transport.

Practical and Cost-Effective Interventions:

EPIC emphasizes practical, cost-effective interventions that don’t require expensive equipment or complex procedures. 

The guidelines are designed to optimize the use of existing tools and techniques, ensuring feasibility for emergency medical services across varying resource levels and locations.

Key Changes Implemented Through EPIC

1. Shift in Airway Management 

• Reduction in intubation rates. 
• Increased use of bag-valve-mask (BVM) ventilation. 
• Evidence shows BVM can provide adequate oxygenation while avoiding complications of intubation in prehospital settings. 

2. Focus on 100% Oxygen Saturation 

• Emphasis on achieving and maintaining 100% oxygen saturation in all suspected TBI cases. 
• Aims to prevent hypoxic secondary injury and improve brain tissue preservation. 

3. Elimination of Hyperventilation 

• Strict attention to ventilation rates:
  • Adults: 10 breaths per minute. 
  • Children: 20 breaths per minute. 
  • Infants: 25 breaths per minute. 
• Avoids hyperventilation-induced vasoconstriction, which can reduce cerebral blood flow and worsen brain injury. 

4. Blood Pressure Management 

• Treatment intervention for systolic blood pressure below 100 mmHg. 
• Ideal target is 110 mmHg or higher to ensure adequate perfusion pressure and blood flow to injured brain tissue. 

These evidence-based changes aim to improve outcomes for TBI patients by focusing on effective, precise, and patient-centered prehospital care.

Survival Rates and Outcomes

Remarkable Survival Improvements Across All Patients 

• Implementation of EPIC guidelines has significantly improved survival rates for traumatic brain injury (TBI) patients. 
• These advancements are among the most important in prehospital emergency medical care in recent decades. 
• Adjusted survival to hospital discharge doubled statewide for severe TBI patients.

Statewide Impact Across Over 21,000 Patients 

• Over 21,000 patients benefited from the implementation of these guidelines. 
• Benefits were observed across all demographics, not limited to specific subgroups or injury types. 
• Adjusted odds ratio of 2.03 means hundreds of lives were saved through this intervention.

Survival Tripled for Intubated TBI Patients 

• Among severe TBI patients requiring intubation, survival rates tripled post-EPIC implementation. 
• This is particularly notable as intubated TBI patients typically have the worst prognosis. 
• The findings highlight the importance of proper prehospital management.

Pediatric TBI: A Paradigm Shift 

• Pediatric patients saw the most dramatic improvement, with a 700% increase in adjusted survival odds. 
• This suggests children are especially vulnerable to secondary brain injury but respond exceptionally well to evidence-based interventions. 
• The results mark a transformative shift in emergency care for children with head injuries.

Simple, Evidence-Based Interventions Behind the Success 

• These outcomes were achieved through straightforward, cost-effective practices. 
• Key focus areas include:
  • Proper oxygenation 
  • Effective ventilation 
  • Blood pressure management 
• Such targeted practices prevent secondary brain injuries, leading to life-saving results.

Training and Implementation Process

Simplicity and Cost-Effectiveness 

• The EPIC guidelines are simple and cost-effective to implement. 
• Training requires just one hour, minimizing disruption to operations. 
• No significant financial investment is needed to train personnel. 

Focus on Practical Skills 

• Training emphasizes hands-on practice and decision-making over theory. 
• Techniques include:
  • Proper ventilation timing. 
  • Oxygen administration. 
  • Blood pressure management. 
• Scenarios mimic real-world situations to enhance learning. 

Free and Accessible Training Materials 

• EPIC 2.0 training materials are free to download for non-commercial use. 
• Removes financial barriers, ensuring equal access across all EMS resource levels. 

Critical Role of the “Bag Person” 

• The ventilation provider is key in traumatic brain injury (TBI) management. 
• Proper ventilation timing and techniques help prevent secondary injuries. 
• Training includes:
  • Two-finger method. 
  • Use of flow restriction devices for accurate ventilation rates. 

Feasibility for All EMS Levels 

• No need for expensive new equipment or major system changes. 
• Focuses on optimizing existing tools and refining techniques. 
• Designed to be realistic for smaller EMS teams with limited budgets.

Importance of Prehospital Care

1. Redefining Emergency Medical Services (EMS) 

• The EPIC guidelines challenge the traditional view of EMS as just a transport service. 
• Prehospital care is established as a critical therapeutic intervention that significantly impacts patient outcomes. 
• This shift redefines the role and responsibilities of emergency medical personnel. 

2. The Impact of Prehospital Care on TBI Outcomes 

• Research shows prehospital care for traumatic brain injury (TBI) patients is crucial in preventing secondary injury. 
• The first minutes and hours after a TBI are critical for preventing further brain damage. 

3. Understanding Secondary Brain Injury 

• Secondary brain injury results from hypoxia, hypotension, and other physiological disturbances after the initial trauma. 
• Unlike primary injury from the impact, secondary injury is preventable with proper medical management. 
• Emergency medical personnel play a direct role in determining patient survival and recovery through timely interventions. 

4. The EPIC Study: Quality Care Over Speed 

• The EPIC study showed that 26 minutes of average EMS on-scene care increased survival to hospital discharge. 
• This highlights the importance of quality care and stabilization over rushing to transport. 
• Prehospital care should prioritize stabilization and treatment rather than focusing solely on rapid transport. 

5. Long-Term Benefits of Prehospital Care 

• Proper prehospital management can prevent mild or moderate TBI from worsening into severe TBI. 
• It can save patients from permanent disability and improve their quality of life after recovery.

Avoiding Secondary Injury

Preventing Secondary Brain Injury: A Primary Focus of EPIC Guidelines 

• Secondary brain injury is the most preventable aspect of traumatic brain injury (TBI) outcomes. 
• Prevention is the primary goal of EPIC guidelines. 
• Emergency medical personnel must understand the mechanisms of secondary injury to optimize patient outcomes. 

Proper Oxygen Treatment Protocols

The Impact of Hypoxia on Secondary Brain Injury 

• Hypoxia is one of the most damaging contributors to secondary brain injury.
  • Even brief periods of low oxygen can lead to brain cell death and worsen outcomes. 
  • The brain’s high oxygen demand makes it especially vulnerable to hypoxic injury after trauma. 

Oxygen administration represents one of the most critical interventions in the EPIC guidelines, with specific protocols designed to maximize brain oxygen delivery while avoiding complications. The approach to oxygen therapy in suspected TBI cases differs significantly from standard emergency medical protocols and requires careful attention to both administration and monitoring.

The Role of Hypotension in Secondary Injury 

• Hypotension reduces cerebral perfusion pressure, leading to:
  • Inadequate blood flow to meet the brain’s metabolic needs. 
  • Increased vulnerability in TBI patients, where autoregulation of blood flow is often impaired. 

The guidelines recommend early and aggressive oxygen treatment with a target oxygen saturation of 100% for any suspected TBI case. This aggressive approach ensures maximum oxygen availability to injured brain tissue and provides a margin of safety against hypoxic episodes that might not be immediately detected.

Risks of Hyperventilation in TBI Management 

• Hyperventilation, though sometimes used to lower intracranial pressure, can worsen brain injury by:
  • Causing cerebral vasoconstriction, reducing blood flow and oxygen delivery. 
  • Compromising brain tissue already struggling to recover after trauma. 

Continuous high-flow oxygen should be initiated for all potential TBI cases, regardless of the apparent severity of injury or the patient’s initial oxygen saturation. This proactive approach prevents hypoxic episodes that could contribute to secondary brain injury and ensures optimal conditions for brain tissue preservation.

How EPIC Guidelines Address Secondary Brain Injury 

• EPIC guidelines provide specific interventions and monitoring protocols to:
  • Prevent or rapidly correct hypoxia, hypotension, and hyperventilation. 
  • Improve patient outcomes by minimizing secondary injury during early care. 

Monitoring oxygen saturation becomes a continuous priority throughout prehospital care, with particular attention to maintaining levels at or near 100%. Any decline in oxygen saturation should prompt immediate intervention to restore optimal oxygenation and prevent hypoxic injury.

The Importance of Proper Prehospital Management 

• Mild to moderate TBI can progress to severe TBI with improper prehospital care. 
• Correct techniques and adherence to protocols during the early stages of care are critical for patient recovery.

The guidelines emphasize that oxygen therapy should be maintained throughout the entire prehospital care period, including during transport. Interruptions in oxygen delivery, even brief ones, can contribute to secondary injury and worsen patient outcomes.

Proper oxygen treatment also involves ensuring adequate delivery systems and backup equipment. Emergency medical personnel should be prepared with multiple oxygen delivery options to maintain consistent, high-flow oxygen regardless of patient condition changes or equipment failures.

Ventilation Management and Hyperventilation Prevention

A Critical Challenge in EPIC Implementation

• Ventilation management is one of the most technically demanding aspects of EPIC implementation.
• It requires precise technique and constant attention to respiratory rate and rhythm.
• The person managing ventilation plays a crucial role, as improper technique can worsen brain injury despite other interventions.

The Dangers of Hyperventilation

• Hyperventilation is strictly prohibited in the EPIC guidelines.
• Although it reduces intracranial pressure by constricting blood flow, it worsens brain injury by reducing oxygen delivery to critical brain tissue.

Recommended Respiratory Rates by Age Group

• Adults: 10 breaths per minute.
• Children: 20 breaths per minute.
• Infants: 25 breaths per minute.
• These rates must be consistently maintained during prehospital care, requiring precise timing and technique.

The Importance of End-Tidal CO2 Monitoring

• End-tidal CO2 monitoring provides essential feedback for proper ventilation management.
• The target range is 35-45 mmHg, with an optimal target of 40 mmHg.
• Monitoring helps prevent both hyperventilation and hypoventilation.

Tools and Techniques for Proper Ventilation

• Technical aids:
  • Ventilator timing lights.
  • Flow restriction devices.
• Two-finger bag-valve-mask technique:
  • Ensures appropriate tidal volumes.
  • Prevents over-aggressive ventilation that could cause hyperventilation.

Training for Effective Ventilation Management

• Hands-on practice with timing devices and monitoring equipment is essential.
• Training helps personnel develop the skills to maintain proper ventilation rates, even under stressful conditions.

Limitations of GCS

• The Glasgow Coma Scale (GCS) is a widely used tool for assessing consciousness levels in patients with traumatic brain injury (TBI). 
• However, it is not always a reliable indicator of TBI severity due to several limitations:
  • It relies on subjective interpretation, which can vary between practitioners. 
  • External factors, such as intoxication, sedation, or preexisting medical conditions, can affect the score and lead to inaccuracies. 
  • Certain injuries, like severe facial trauma or swelling, may prevent an accurate assessment of verbal and motor responses. 
• While the GCS remains a valuable tool, clinicians should use it alongside other diagnostic methods and consider the broader context of the patient’s condition.

EPIC Project Details

• The Excellence in Prehospital Injury Care (EPIC) project is designed to improve outcomes for traumatic brain injury (TBI) patients through evidence-based prehospital care. 
• Key goals include:
  • Educating and training emergency medical personnel (EMPs) on best practices. 
  • Focusing on critical aspects like oxygenation, ventilation, and blood pressure management during prehospital treatment. 
• The project emphasizes:
  • Team training to ensure cohesive and effective care delivery. 
  • Using advanced technologies to enhance prehospital interventions. 
  • Establishing standardized protocols to bridge the gap between research and real-world application. 
• By implementing these practices, EPIC aims to boost survival rates and improve neurological outcomes for TBI patients.

Criticisms of Traumatic Brain Injury Guidelines

• The Brain Trauma Foundation published the “Guidelines for the Management of Severe Head Injury” in 1996, offering comprehensive recommendations for treating TBI. 
• These guidelines marked a significant step forward in evidence-based care. 
• However, their adoption into clinical practice has faced several challenges:
  • Limited access to updated training for medical professionals. 
  • Resistance to changing long-standing practices. 
  • Resource constraints in implementing the guidelines effectively. 
• Despite nearly 30 years since their publication, the guidelines have not been uniformly adopted by many medical experts and emergency personnel (MEPs). 
• These challenges emphasize the need for ongoing efforts to promote adherence to evidence-based standards in medical care.

FAQs

Conclusion

Implementing the EPIC guidelines presents numerous benefits, including improved patient outcomes, reduced mortality rates, and enhanced prehospital care for patients suffering from traumatic brain injuries. By equipping emergency personnel with evidence-based tools and strategies, the EPIC initiative has the potential to set new standards in TBI management.

Readers are encouraged to learn more about the EPIC project and consider incorporating these guidelines into their practice to ensure better care for TBI patients. By doing so, healthcare professionals can make a profound difference in the lives of individuals impacted by severe head injuries.

Beth Skwarecki

Beth is Cloudmineinc’s senior health editor and a certified personal trainer. She has over 10 years experience as a science journalist and is the author of two books. She deadlifts over 315 lbs.